Self-harm is an umbrella term for a range of ways in which individuals can intentionally hurt themselves. People self-harm for a variety of reasons; it may be in response to a specific incident or situation, or it may become part of how someone tries to deal with on-going problems.

NICE has guidance on both the short-term and longer-term management of self-harm, which recommend that psychosocial interventions (that are specific to self-harm and tailored to the individual) be offered to people who have self-harmed.

A recent study was undertaken by researchers based in Denmark to see whether receiving psychosocial therapy after self-harm reduced people’s risk of repeated self-harm, suicide and general mortality (Erlangsen et al, 2014).

Methods

This cohort study matched 5,678 people who had self-harmed and subsequently received psychosocial therapy, with 17,034 people who had self-harmed but did not receive psychosocial therapy (standard care).

Psychosocial therapy varied across the different clinics and interventions were tailored to suit individuals’ needs, but the overall focus was on suicide prevention delivered over eight to 10 outpatient sessions. Standard care was admission to a psychiatric hospital, referral to outpatient treatment or general practitioner, or discharge with no referral. Where individuals did not receive psychosocial therapy it was usually because such services were not available or because they were referred to an alternative treatment.

The study used data from medical records at seven suicide prevention clinics across Denmark between 1992 and 2010.

Individuals were matched based on several demographic factors such as sex, age, level of education, experience of foster care, psychological diagnoses and family history of suicidal behaviour.

The outcomes measured were repeated self-harm, death by suicide and death by any cause.

This ecological study included a wide variety of different brief (8-10 sessions) psychosocial therapies.

Results

Repeated self-harm was reduced in those participants who received psychosocial therapy at the 20 year follow-up (OR 0.84; 95% CI 0.77 to 0.91) and was consistently lower over the follow-up period.

Death by suicide was significantly lower at five, 10 and 20 years, but the difference at one year was not statistically significant (p=0.1531).

Death by any cause within a year was significantly lower over the 20 year follow-up (p=0.0006 in year one, p=<0.0001 for years five, 10 and 20).

Subanalyses revealed that psychosocial therapy was more effective at reducing future self-harm and death by suicide in women than men, and more effective in adolescents (10-24 years old).

Over the twenty year follow-up period, researchers calculated that the psychosocial intervention prevented 145 incidents of deliberate self-harm, 30 deaths by suicide and 153 deaths by any cause.

Psychosocial therapies were associated with a lower risk of future deliberate self-harm and death by any cause.

Conclusions

The authors concluded:

Our findings show a lower risk of repeated deliberate self-harm and general mortality in recipients of psychosocial therapy after short-term and long-term follow-up, and a protective effect for suicide after long-term follow-up, which favour the use of psychosocial therapy interventions after deliberate self-harm.

The treatment effects seemed more pronounced in women, young people and first attempters of suicide.

Summary

This cohort study shows that psychosocial therapy is effective in reducing repeated self-harm, death by suicide and death by any cause in the short-term (one year) and over the longer-term (20 years) in people who have self-harmed. The study is useful in demonstrating the overall effectiveness of psychosocial therapy in a large sample.

However, the psychosocial therapy delivered by the clinics varied, so it is not possible to specify what type of therapy is most beneficial, which the authors acknowledge as a limitation of their study.

There is general consensus that psychosocial therapy is effective in people who self-harm, there is still uncertainty about what type of therapy to offer (e.g. brief interventions) and about which elements of therapy are most effective. Therefore it would be helpful if future research could focus on identifying those “active ingredients” for effective psychosocial therapy in people who have self-harmed.

The panoply of included therapies in this study make it extremely difficult to identify the “active ingredient” that is helping people.

If you need help

If you need help and support now and you live in the UK or the Republic of Ireland, please call the Samaritans on 116 123.

Elly is an Information Specialist, specialising in healthcare. Mental health is a particular area of interest, having worked on a range of mental health related projects. Elly is interested in communicating and explaining mental health research to a wider audience.

I think it’s important to acknowledge the substantial research that has been conducted that substantiates the fact that self harm, suicide, and bpd are all highly correlated with sexual abuse histories and childhood trauma (see: van der Kolk, Herman et. al) This is not mentioned in the article. Also, the notion that self harm and suicide rates can be sufficiently addressed by short term therapeutic intervention (8 to 10 sessions) is absurd given the etiology of self harm. The desire for a ‘quick fix’ and economic incentive will always be there given the nature of managed care. Psychotherapy can be of some help, but this is not the ideal form of treatment. People with trauma histories need to learn to work with their bodies, learn relaxation skills and the ability to self regulate. This requires specific kinds of intervention and therapy not made readily available and accessible to most people. This is often viewed as ‘alternative’ because it is not mainstream, but not because it is ineffective treatment, rather it is inaccessible treatment often not reimbursable by insurance. Still, it also stands to reason that some form of psychotherapy would be better than none. A therapeutic alliance can serve as a “lifeline” to those who would otherwise have no other form of human connection or support.